Nozomi Takeshita 1 and Shuzo Kanagawa 1 “
“We present a case EPZ015666 mouse of progressive disseminated histoplasmosis in an immunocompetent traveler. Histoplasmosis was acquired in South America; its manifestations included prolonged fever, splinter hemorrhages, erythema multiforme, arthritis, and mediastinal lymphadenopathy.
To the best of our knowledge no splinter hemorrhages had previously been reported in a patient with histoplasmosis. Histoplasmosis is an uncommon disease in returning travelers. We present a case of progressive disseminated histoplasmosis with unusual clinical manifestations. A 64-year-old previously healthy male was admitted for investigation of fever up to 39°C and night sweats that appeared 6 weeks prior to admission. The patient was an avid traveler, and participated in jogging and cycling nearly daily. Symptoms first appeared 7 days after a 1-week trekking tour in Jordan, 3 weeks after a 1-month tour in Bolivia and Brazil, and 6 months after a tour in Angola and Ethiopia. The patient had participated in white
water rafting in Africa and jungle trekking in South America. There was no history of cave exploration or exposure to bats on either trip. On admission, fever, weight loss, conjunctivitis, and a rash involving the dorsal aspects of both hands were noted. As time passed, fever gradually decreased, but weight loss progressed, and splinter hemorrhages (Figure 1), polyarthralgia, and arthritis of the ankles and knees developed. Blood count revealed mild normocytic anemia consistent with anemia related
to chronic inflammatory disease. Blood chemistry showed mild hypoalbuminemia, Pictilisib clinical trial but was otherwise unremarkable. Erythrocyte sedimentation rate was 50 mm/hour, and C-reactive protein 24 mg/L (normal level 0–5). Additional tests including angiotensin converting enzyme level and a complete rheumatic panel were normal. Abdominal and chest CT scan revealed hilar and mediastinal lymphadenopathy with several pulmonary nodules (Figures 2 and 3). Transesophageal echocardiography Buspirone HCl (TEE) showed no valvular abnormalities or evidence of vegetations. The clinical diagnosis of erythema multiforme was supported by the findings of a skin biopsy. Blood and bone marrow cultures for bacteria and mycobacteria were sterile. Serologic tests for Q fever, Rickettsia, Brucella, Leishmania, HIV, Epstein–Barr virus, and cytomegalovirus were negative. Blood smears for malaria and Borrelia were negative as well. Ten weeks after the onset of symptoms a serologic test for histoplasmosis was submitted to the Centers for Disease Control and Prevention, but was inconclusive. Biopsy of a mediastinal lymph node revealed necrotizing granulomas. Ziehl–Neelsen, silver and periodic acid-schiff stains were negative for mycobacteria and fungi. Culture and PCR for mycobacteria were negative. The lymph node pathology sample was cultured on Sabouraud dextrose agar slant.